Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data  Tanwei Yuan, MD, Thomas Fitzpatrick, BA, Prof Nai-Ying Ko, PhD, Prof Yong Cai, PhD, Prof Yingqing Chen, PhD, Jin Zhao, PhD, Linghua Li, PhD, Prof Junjie Xu, PhD, Jing Gu, PhD, Jinghua Li, PhD, Chun Hao, PhD, Zhengrong Yang, PhD, Weiping Cai, MD, Chien- Yu Cheng, MD, Zhenzhou Luo, MD, Kechun Zhang, MD, Guohui Wu, MD, Xiaojun Meng, MD, Prof Andrew E Grulich, PhD, Prof Yuantao Hao, PhD, Prof Huachun Zou, PhD  The Lancet Global Health  Volume 7, Issue 4, Pages e436-e447 (April 2019) DOI: 10.1016/S2214-109X(18)30567-9 Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 1 Selection of reports for inclusion in meta-analyses STI=sexually transmitted infection. MSM=men who have sex with men. The Lancet Global Health 2019 7, e436-e447DOI: (10.1016/S2214-109X(18)30567-9) Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 2 Meta-analysis and cumulative meta-analysis of the association between circumcision and HIV infection among men who have sex with men In the cumulative meta-analysis, studies were sorted by year of publication and sequentially added to the analysis in chronological order, with pooled estimates recalculated with each added study. All estimates are independent. One study could contribute more than one estimate only when data from independent populations were analysed and reported separately. Blue vertical dotted line shows the overall odds ratio. The Lancet Global Health 2019 7, e436-e447DOI: (10.1016/S2214-109X(18)30567-9) Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 3 Subgroup meta-analyses of the association between circumcision and HIV infection among men who have sex with men Cutoffs for continuous variables were median values. OR=odds ratio. MSM=men who have sex with men. LGBT=lesbian, gay, bisexual, and transgender. The Lancet Global Health 2019 7, e436-e447DOI: (10.1016/S2214-109X(18)30567-9) Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 4 Meta-analysis and cumulative meta-analysis of the association between circumcision and any sexually transmitted infection other than HIV among men who have sex with men In the cumulative meta-analysis, studies were sorted by year of publication and sequentially added to the analysis in chronological order, with pooled estimates recalculated with each added study. To ensure the independence of effects, each study contributed only one estimate unless data from independent populations were analysed and reported separately. If a study reported multiple individual association estimates between circumcision and different infection sites or STIs in the same population, a summary odds ratio of all STIs (excluding HIV) was calculated for that study population, using the formula developed by Borenstein and colleagues.59 Blue vertical dotted line shows the overall odds ratio. STI=sexually transmitted infection. The Lancet Global Health 2019 7, e436-e447DOI: (10.1016/S2214-109X(18)30567-9) Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 5 Meta-analyses of the associations between circumcision and specific sexually transmitted infections among men who have sex with men Associations between circumcision and anal HPV infection and penile HPV infection were calculated separately and stratified by HIV status of participants. STI=sexually transmitted infection. MSM=men who have sex with men. HPV=human papillomavirus. HSV=herpes simplex virus, including both HSV-1 and HSV-2. HBV=hepatitis B virus. NE=not estimable. The Lancet Global Health 2019 7, e436-e447DOI: (10.1016/S2214-109X(18)30567-9) Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions